Does This Black Cloud Have a Silver Lining?

Your intern has captured multiple views of the gallbladder, which appears to be contracted with a thickened wall. Since wall thickness measurements are only useful for a dilated gallbladder, you move on. You note a faint acoustic shadow coming off the middle of the gallbladder; likely from a small intraluminal gallstone or dense collection of sludge (Image 1). As you scroll through the rest of his images, you pause to evaluate his images of the surrounding liver parenchyma. You note that the parenchyma doesn’t have the normal homogeneous appearance that you are used to seeing on your bedside scans. In fact, you think you make out three very distinct masses near one of the hepatic veins.

You confirm your intern’s suspicions that “something just ain’t right” and go with him to explain to the patient that more comprehensive imaging is warranted during her evaluation tonight. On further review, the patient states that she has unintentionally lost weight in the past few months, and that the pain may have been there longer than she was willing to acknowledge. She has been putting off her family’s recommendations to see a doctor because she was afraid of what it could be. After a lengthy conversation with her, she thanks you both for your comprehensive care and for helping to expedite her diagnosis and work-up.

You walk back to your computer with your head hung low to catch up on your dictations about all of the sad cases you’ve seen today, and you notice a piece of paper resting on top of your keyboard. Your colleague has left you a drawing of a single black cloud with a silver lining etched through the middle with the words “Dear Dr. Black Cloud…remember you are making a difference…” With a small smile, you pin the picture next to your desk and then move on to the next chart.